Anyone who has accompanied a loved one to an emergency room knows how challenging it can be to navigate the medical system. Its complex language, daunting costs, and frenetic pace make it difficult for the average person to take in. If the patient has no one by their side and if they are dealing with two or more chronic conditions — plus poverty, food insecurity, and unstable housing — they face even greater challenges in navigating the healthcare system.

Sarah Williams, Lamoille County Mental Health Services (LCMHS) Medical Care Coordinator, has seen first-hand the results of that confusion and it has become her mission to directly challenge that problem. In her role, Williams has created collaborative relationships among providers at LCMHS and community partners, including primary care physicians, endocrinologists, neurologists, pharmacists, and hospital emergency room staff. Her role brings together providers and information systems to coordinate health services with patient needs to better achieve the goals of treatment. “When I look into a person’s eyes, I can see the difference that help has made. They are less stressed and can focus on getting well.”

Having someone to help patients navigate a complex system improves the quality of the care they receive. Outcomes improve as well, as the person receives the kind of medical follow-up that is required to treat their needs. Research across disciplines have shown that care coordination increases efficiency and improves clinical outcomes and patient satisfaction with care. “Greater coordination of care—across providers and across settings—will improve quality care, improve outcomes, and reduce spending, especially attributed to unnecessary hospitalization, unnecessary emergency department utilization, repeated diagnostic testing, repeated medical histories, multiple prescriptions, and adverse drug interactions” writes Susan Salmond and Mercedes Echevarria of Rutgers University School of Nursing.

Through these coordinated partnerships, LCMHS is enhancing the quality of care for the individuals they serve. This gives the individual an advocate, as well as someone to translate the often murky landscape of multiple disciplines of medicine. This has a striking benefit to patients’ mental health, quality of life, and their own sense of optimism as they have one distinct person that can be contacted to help clarify information, track multiple appointments, and identify specialists.

As primary and behavioral health care providers strive to integrate services, care coordination will support system-wide efforts to reduce emergency room visits and hospital stays, which is one of the greatest cost-drivers for the health care system. Based on the foundation of care coordination, primary and behavioral health care integration will make huge inroads in achieving the triple bottom line of health care: to improve the health of the population, to improve the patient experience of care (including quality, access, and reliability), and to control or reduce costs.

Rebecca Copans has worked extensively in government affairs, public relations and communications. As a society, our greatest potential lies with our children. With this basic tenant firmly in mind, Rebecca worked most recently with the Permanent Fund for Vermont’s Children and now with Lamoille County Mental Health to secure a stronger foundation for all Vermont families.

A graduate of the University of Vermont and Dartmouth College, Rebecca holds a bachelor’s degree in political science and a master’s degree in globalization. Her thesis concentration was the history and societal use of language and its effect on early cognitive development. She lives in Montpelier with her husband and three children.

A fiber rich diet has many benefits to a healthy lifestyle. It can reduce your risk of heart disease and type 2 diabetes, as well as several kinds of cancer. It also can improve cholesterol, lower blood pressure, regulate digestion and help with weight loss. With farmers markets and CSA’s (Community Supported Agriculture) in full swing now, eating locally produced, fiber-rich foods is both easy and delicious!

What is FIBER?

There are 2 kinds: soluble and insoluble. Soluble fiber can help control blood sugar and cholesterol, while insoluble fiber adds bulk to our colon and can act like a brush, helping food pass through the digestive tract more efficiently. Fiber can be found in fruits, veggies, whole grains, nuts and beans.

What is a WHOLE GRAIN?

A whole grain has 3 layers: the fiber-rich bran or outer layer, the endosperm or middle layer, and the germ or inner layer. Whole grains are not only rich in fiber, but also are loaded with nutrients. Some examples include whole grain breads, oats, corn meal, bulgur, quinoa, brown rice, farro and popcorn. A refined grain is processed leaving only the middle or endosperm layer is left, thus removing much of the beneficial fiber and nutrients.

How much is ENOUGH? It is generally recommended that people consume 25 to 38 grams of fiber each day. Add fiber to your diet slowly, over a few weeks. Too much too fast can cause bloating or gas.

Read labels! Choose breads, cereals, pasta and crackers that list ‘Whole Grain’ as the first ingredient. Look for the ‘Whole Grain’ stamp on the package and beware of deceptive marketing. ‘Multi Grain’, ‘wheat’ and ‘enriched flour’ do NOT mean whole grain. Products with at least 10% of the ‘percent daily value’ are generally fiber-rich foods.

Rorie Dunphey works under Vermont’s Blueprint for Health as the RN Chronic Care Coordinator at Family Practice Associates in Cambridge. She works one-on-one with people and also leads classes to promote health and help people better manage their chronic diseases. She also assists patients in accessing community and state resources to better coordinate their health and wellness needs. Rorie has a particular passion for promoting a healthy diet and exercise routine to inspire people to live their best life.

Healthy People 2020 defines social determinants of health as “the conditions in which people are born, live, work, and age that affect their health.” They include factors such as education, the safety of our homes and neighborhoods, financial security, the cleanliness of our water and air, access to good nutritional food, etc.

Care coordination is a collaboration between providers, social services and the patient themselves. It often sounds simpler than it actually is. Let’s be clear: one meeting doesn’t lead to change. Thoughtful, consistent care coordination involving the patient and all members of their care team is needed over the long term to help someone become healthier. That care team can include local health care providers, substance abuse counselors, mental health counselors, RN case managers, social workers and a variety of other case managers from across local agencies.

So how does it work? Let me share a few examples. (Note: We have changed names to protect privacy.)

The Right Care in the Right Place at the Right Time
Copley recently treated Joe in our ED and, due to the severity of his illness and the resources required to manage his care, transferred him a tertiary hospital. His health improved but he still needed weeks of inpatient skilled nursing and complex care coordination to ensure once he was home, he had a secure social support network to assist him. Joe wanted to be cared for at Copley as it was closer to home and easier for his family to participate in his care. The tertiary hospital was reaching capacity, and, coupled with the need for local care coordination and Joe’s preference, contacted Copley. There was no question that Copley could provide the medical care, but we weren’t sure if we would be able to meet his other needs to ensure a smooth transition. After three weeks of collaborative teamwork with nurses, providers, pharmacists, care managers, social workers, Chaplaincy, nurse leaders, and the patient himself, a plan was developed to address both Joe’s social and clinical issues so he could be admitted to Copley and provided with the appropriate continuation of care. Joe was able to receive the inpatient skilled nursing care and complex care coordination he needed in a more affordable setting, closer to home.

Reducing Avoidable Emergency Department (ED) Visits
John is a middle-aged man who has come to Copley Hospital’s Emergency Department nearly 40 times in the past two years. In addition to his alcoholism, John struggles with mental health issues and has a long cardiac health history. He is considered a “super-utilizer” of medical services. Copley has a full-time social worker in our ED as part of an Emergency Department Care Coordination pilot with Community Health Services of Lamoille Valley. The social worker assesses the patient’s needs 1:1 either at the bedside or through a follow-up call. Copley’s social worker was able to connect with John 1:1 in the ED earlier this year.

Copley’s social worker subsequently met with John each time he presented to the emergency department and followed up each visit with a phone call to review discharge plans and follow-up appointments. With John’s permission, she kept each of his various providers informed after each visit. After several visits, John met with Copley’s ED social worker and his primary care RN care coordinator to talk about his goals and what he thought he needed to be successful. Two weeks later, he decided he was ready for treatment and came to the Emergency Department for help. Copley’s ED team, inpatient medical social worker, and ED social worker all worked throughout the day to help get him admitted into an appropriate facility for inpatient alcohol treatment.

The ED social worker continued to check in with the inpatient facility and advocate for John. He was able to remain in the program for a longer period of time and she coordinated transportation with Rural Community Transportation (RCT) in advance for his follow-care plan appointments. Forty-eight hours after discharge, John met with his primary care RN care coordinator to review his discharge plan and ensure he had what he needed to be successful. Copley’s ED social worker continued to contact John and his providers regularly, confirming he had attended appointments with his substance abuse counselor, psychiatrist, primary care provider, specialist appointments, and RN care coordinator. This plan was followed for four weeks, at which point, John’s ongoing case management was transferred to his primary care RN case coordinator.

The outcome? John has maintained his commitment to make healthier choices. The shared care plan continues, with the goal of eliminating future costs of avoidable visits to the ED, by keeping John and patients like him, feeling engaged, motivated, and supported to make healthy choices.

Reducing CostsCopley Hospital recently participated in an initiative to reduce the percentage of ED visits of 29 identified “super-utilizers” by implementing a shared care plan. The 29 “super-utilizers” accounted for 4% of the total ED visits in the initial 90-day time period; they accounted for only 1% in the second 90-day time period. A potential $144,300 was saved by this decrease in ED visits. This collaborative initiative involved Blueprint for Health Medical Homes (Community Health Services of Lamoille Valley, Northern Counties Health Care, Family Practice Associates in Cambridge and other primary care practices), Vermont Chronic Care Initiative with the Vermont Department of Health, and other local health agencies along with Copley Hospital.

These are just three examples of care coordination at Copley. We plan to continue the ED Care Coordination pilot, with Copley helping to fund the social worker position in the ED. However, we know this will not be enough to meet the need. We continue to strive to provide excellent patient care for needed services and invest in programs to help reduce the rising cost of health care. Copley will continue to advocate for and contribute to shared care plans to connect patients with needed health services and social determinants support, collaborating with existing organizations and resources, to help patients make healthy choices.

Leah Hollenberger is the Vice President of Marketing, Development, and Community Relations for Copley Hospital. A former award-winning TV and Radio producer, she is the mother of two and lives in Morrisville. Her free time is spent volunteering, cooking, playing outdoors, and producing textile arts. Leah writes about community events, preventive care, and assorted ideas to help one make healthy choices.

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It is essential that you seek professional advice for all issues concerning your health. Do not take any of the information in this blog (either in posts or comments) as professional advice or official communication from Copley Hospital or any of the blog authors. Posts and comments on this blog are not intended to be professional advice, unless implicitly indicated in the blog post, and do not necessarily reflect Copley Hospital policy or corporate opinion. The opinions and/or views expressed on Live Well Lamoille represent the thoughts of the individual bloggers and commenters, not those necessarily of the organizations they represent or organizations affiliated with the blog.

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